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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1-YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welUpump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 2307 Waudman Avenue City Stockton Lot Size PM Owner's Name W.E . Gibson Address 2307 Waudman Avenue Phone 477-2538 Contractor Clark Well, Inc. Address 202'4 E" Charter License No. 371560 `one 462-7676 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION IX SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing X Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I"I Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout--..-- [ rout .._i 1 Irrigation —..Approx. Depth I I EasternSurface Seal Installed by Repair Work Done ❑ Type of Pump Sub H.P. State Work Donenst fled Well Destruction ❑ Well Diameter Sealing Material (top 50;") ' Depth Filler Material (Below 501 " — TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION i,l DESTRUCTION I I (No septic system permitted-if public sewer is f1 available within 200 feet.) J Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms s" Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg /f Capacity No. Compartments PKG. TREATMENT PLT. ❑ F Method of Disposal ik Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines — _ Total length/size FILTER BED CIDistance to.neaest: Well. - Foundation Property Line SEEPAGE PITS 1 1 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONOS ❑ I hereby certify that i have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home own licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not emptoy an pe on in`such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies th foll wing: 11c ify that in t perform a of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws C Iifia. orn ' r The applic u t call for qui e n pectio Complete drawing on reverse side. Sec-Tres 12 Feb 90 Signed.X Title: Date: s FOR DEPARTMENT USE ONLY + Application Accepted by 71h Date ?_L ' — 1 Pit or Grout Inspection by Date Final Inspection by Date 3 2 Additional Comments: I' ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO Ikk +.EH 13-241REV.1/x5) 0 EH 14-26